Responding to the Needs of Justice Involved Persons with Mental Illnesses: Screening and Assessment

1. Responding to the Needs of Justice Involved Persons with Mental Illnesses: Screening and Assessment Fred C. Osher, MD Director of Health Systems & Services Policy July 24, 2008

2. Dear Abby……….

3. CSJ Justice Center: National Projects

5. Council of State Governments Justice Center: Florida Activities • NIC Learning Site • Chief Justice Initiative • Collaboration with FMHI

6. Goals of Presentation • Overview and Context • Target Population and Program Design • Screening and Assessment • Supervision and Treatment Planning • Evidence Based Practices

7. Skyrocketing Criminal Justice PopulationsBureau of Justice Statistics, 2005

8. Scope of the Problem • Over 14 bookings into U.S. jails each year • Over 9 million adults • Over 1,000,000 will have serious mental illnesses • ¾ of these will have co-occurring substance use disorders • The vast majority will be released to community

9. GAINS, 2004

10. GAINS, 2004

11. Co-Occurring Substance Use Disorders Among Jail Detainees with Serious Mental Disorders • % With Co-Occurring Substance Use Disorders • % Without Co-Occurring Substance Use Disorders GAINS 2004

12. Goals of Presentation • Overview and Context • Importance of Target Population and Program Design • Screening and Assessment • Supervision and Treatment Planning • Evidence Based Practices

13. Diversion ProgramsLogic Model Steadman, Osher, Naples Stage 1Stage 2 Identify Target Group Comprehensive/Appropriate Community Treatment Diversion Improved Public Safety Outcomes Improved Mental Health Outcomes Stage 3 - Outcomes

14. Target Population and Program Design: Three Questions • Who is your target population? • What will you do for them? • How will you sustain your program?

15. Defining the Target Population Finding your target population – not so simple

16. Finding the Target Population SCREENING FOR MHPTR ELIGIBILITY

17. Defining the Target Population

18. Impact of Target Population on Outcomes: Pennsylvania Comparisons of Simulation Models

19. Some Common Front-end Pitfalls • Vague criteria for target group • Missing key people in planning • Overly ambitious goals • EBP’s: what are they and where are they? • Workforce capacity and workforce quality

20. Goals of Presentation • Overview and Context • Target Population and Program Design • Screening and Assessment • Supervision and Treatment Planning • Evidence Based Practices

21. Mental health service delivery begins with identification • Three stage process: • Screening • Assessment • Supervision/Treatment Planning

22. Objective and Comprehensive Screening and Assessment Cognitive Therapy Vocational SA Treatment Housing Medication Screening, Assessment, and Treatment Planning Screening for Need/Risk (NIDA, 2006)

23. Definition: Screening • A formal process of testing to determine whether an inmate does or does not warrant further attention at the current time in regard to a particular disorder and, in this context, the possibility of a mental disorder. • The screening process for mental illnesses disorders seeks to answer a “yes” or “no” question. Might a mental illness exist? • Note that the screening process does not necessarily identify what kind of problem the person might have, or how serious it might be, but determines whether or not further assessment is warranted.

24. Screening for Mental Illnesses

25. Why screen for mental illness? • Jail populations have 3-4 times higher rates of mental illness than the general population • Public health opportunity • U.S. Supreme Court has held that jails and prisons are obligated to provide mental health care • Critical to jail management • Essential for rapid engagement in specialized treatment and supervision programs

26. What else to screen for ? • Suicide Risk • Substance Use Disorders • Motivation • Criminogenic Risk

27. Features of Useful Screening Instruments • High sensitivity (but not high specificity) • Brief • Low cost • Minimal staff training required • Consumer friendly

28. Historic lack of adequate mental health screening • 83% of jails provide some screening Steadman and Veysey (1997) • Only 37% of jail detainees with severe mental disorder were identified during routine screening Teplin (1990) • Recent use of data matching programs

29. NIJResearch • Develop a brief jail mental health screening tool to be used by correctional staff on all jail admissions • Brief • Easy to use • Clear decision criteria • Balance false negative and false positive rates • Validate the tool to confirm its utility and make available to U.S. jails

30. Brief Jail Mental Health Screen:ResearchApproach • Use the screen in four jails for eight months at two points in time • Administered structured clinical interview (SCID)to a sub-sample of inmates • Compare the screens with the clinical interviews for validation

31. Validation study • Screened over 20,000 inmates • Sampled 100 inmates at each jail • Stratified by status (urgent, routine, non-referral) and gender • Administered the Structured Clinical Interview for DSM-IV (SCID) • Identified false positives and false negatives rates and appropriate scoring cut-offs

32. Validation Results • Males • 80 % correctly identified • 64% sensitivity • 84% specificity • 8% False Negatives • Females • 72% correctly identified • 61% sensitivity • 75% specificity • 14% false negatives

33. BJMHS - Conclusions • A useful, cost-effective tool for screening men and women booked into U.S. jails • Reasonable referral rates (11 – 16%) • 8 questions can be administered by corrections staff in 2 – 3 minutes • NIJ – “based on successful validation results, it is anticipated these tools will be disseminated nationwide for use in all correctional facilities”

34. ScreeningforSuicideRisk

35. Suicide and Corrections • Suicide is a primary cause of death in many county correctional facilities • It takes a team to prevent suicide • The correctional officer has the most critical role in suicide prevention • Most suicides can be prevented when the team knows what to look for and what to do • Liability is reduced significantly when the team understands and follows the suicide prevention plan.

36. Suicide Prevention (BJS, 2005) • Jail suicide rates – 47/100,000 • Rates in 50 largest jails (29/100,000) • Suicide rates are declining steadily nationally • No longer leading cause of death at 32.3% (now illness at 47.6% is leading cause) • Nearly ½ of jail suicides occur in first week of custody • The importance of screening

37. Suicide Intake Screening • Suicide Prevention Screening Guidelines Form • Takes less than 5 minutes to fill out • Devoted exclusively to identifying suicidal behavior in arrestees • Encourages communication between arresting/transporting and booking officers • Guidelines for acute referral • Standardized training available • Used in conjunction with BJMHS

38. SuicidePrevention– morethan a screeninginstrument • Initial screen and periodic assessment • Suicide prevention training for correctional, medical, and MH staff • Levels of communication between outside agencies, among facility staff, and with the suicidal inmate • Suicide resistant, protrusion free housing for suicidal inmates • Level of supervision for suicidal inmates • Timely emergency interventions following attempts • Critical incident stress debriefing to affected staff and inmates, as well as a multidisciplinary mortality review of suicides and serious attempts

39. Screening for Substance Use Disorders • TCU Drug Dependence Screen – II • High overall accuracy • Tested in jail and prison settings • Brief, easy to score with low, medium, and high cut-off points • Simple Screening Instrument • High accuracy, tested in corrections • Brief, easy to score

40. ScreeningforMotivation • Useful in matching to scarce treatment resources • Caution: Motivation as state, not trait • Available measures • SOCRATES – stages of change readiness and treatment eagerness scale • URICA – University of Rhode Island Change Assessment Scale

41. ScreeningforCriminogenicRisk • Long history in c-j settings • Useful in determining supervision intensity • Potential application for assignment ot cognitive behavioral programs • Brief Screens in Development – Austin 8 item scale • LSI-R, WISC –R, COMPASS

42. Definition: Assessment • A basic assessment consists of gathering key information and engaging in a process with the client that enables the counselor/therapist to understand the client’s readiness for change, problem areas, COD diagnosis, disabilities, and strengths. • An assessment typically involves a clinical examination of the functioning and well-being of the client and includes a number of tests and written and oral exercises. The COD diagnosis is established by referral to a psychiatrist or clinical psychologist. • Assessment of the COD client is an ongoing process that should be repeated over time to capture the changing nature of the client’s status.

43. Acute Safety Needs Quadrant Assignment Level of Care Diagnosis Disability Strengths and Skills Recovery Support Cultural Context Problem Domains Phase of Recovery/Stage of Change DomainsofAssessment

44. The “Best” AssessmentTool

45. AnAssessmentApproach: The APIC Model of Transition Planning for Persons With SMI Leaving Jails

46. Outcomes of Inadequate Transition Planning • Compromised public safety • Increased psychiatric disability • Relapse to substance abuse • Hospitalization • Suicide • Homelessness • Re-arrest

47. Jails vs. Prisons • Jails hold both detainees awaiting court appearances, persons awaiting sentencing, AND inmates serving short term sentences • Short episodes of incarceration • Inmates less likely to have lost contact with community supports • Unpredictable nature of jail release

48. Assess Plan Identify Coordinate Assess the inmate’s clinical and social needs, and public safety risks Plan for the treatment and services required to address the inmates needs Identify required community and correctional programs responsible for post-release services Coordinate the transition plan to ensure implementation and avoid gaps in care with community-based services The APIC Model

49. ASSESS • Begins with identification of inmate with mental illness • Screening and Referral • Need for valid and reliable screening measures • Applied to every newly admitted inmate during routine intake process • Conducted by correctional staff • “red flags” result in need for discharge planning • Obtain old records • Engage the consumer in the transition process

50. PLAN • Planning must be multidisciplinary • Address short-term and long-term needs • Critical time intervention • What has worked before? • Seek family input